The psychiatric-mental health nurse is performing the admission assessment of a client who is being admitted for depression and anxiety. The client reports a long history of excessive alcohol use and the recent loss of her job. When the nurse asks whether she has a religious preference or affiliation, the client states. "I used to believe in God, but I do not anymore. I do not understand how God can allow terrible things to keep happening to me.' Which nursing diagnoses will the nurse include in the client’s care plan?
Risk for lack of faith
Risk for spiritual distress
Risk for impaired religiosity
Risk for impaired spirituality
The Correct Answer is B
The client's statement about losing faith in God and not understanding how God could allow bad things to happen to her suggests that she is experiencing spiritual distress. This can be common among individuals experiencing depression and anxiety, as they may struggle to find meaning or purpose in their lives.
Option a, Risk for lack of faith, is not a recognized nursing diagnosis.
Option c, Risk for impaired religiosity, may be more appropriate for a client who has experienced a significant change in their religious practices or beliefs but does not necessarily indicate distress.
Option d, Risk for impaired spirituality, could be appropriate but may be too broad and not specific enough to the client's situation.
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Correct Answer is D
Explanation
Explanation: Manipulation involves using indirect, underhanded, or deceptive tactics to control or influence others. In this statement, the speaker is using a veiled threat to control the behavior of another person.
This is an example of manipulative behavior, and the nurse should recognize it as such.
Option A is an example of a statement seeking clarification, not manipulation. The sibling is asking a question about the behavior of the other sibling.
Option Ais an example of a statement aimed at understanding the other person's behavior, not manipulation.
Option Cis an example of taking responsibility for one's actions and setting boundaries, not manipulation
Correct Answer is D
Explanation
This response encourages the client to share her thoughts and concerns about returning to school, which can help the nurse to understand the client's perspective and provide support and guidance as needed. It also shows that the nurse is actively listening and interested in what the client has to say, which can help to build trust and rapport in the therapeutic relationship.
Responses a and b are positive but not necessarily helpful in addressing the client's concerns.
Response c is potentially intrusive and could make the client feel uncomfortable or judged.
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